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Two hours after the client’s vaginal delivery, she reports feeling “several large, warm gushes of fluid” from her vagina. The nurse assesses the client’s perineum and finds a large pool of blood on the client’s bed. Which nursing action is priority?
- A. Encourage the client to ambulate to the bathroom in order to empty her bladder.
- B. Place two hands on the uterine fundus and prepare to vigorously massage the uterus.
- C. Reassure the client that heavy bleeding is expected in the first few hours postpartum.
- D. Support the lower uterine segment with one hand and assess the fundus with the other.
Correct Answer: D
Rationale: A full bladder may displace the uterus, causing increased bleeding. However, a more complete assessment must be performed prior to getting the client out of bed to prevent increased bleeding and syncope. Vigorously massaging the uterus may result in inversion of the uterus. The client should not simply be reassured that heavy bleeding is expected because further assessment is necessary before concluding that the client’s blood loss is WNL. The nurse’s first action should be to support the lower uterine segment and to assess the fundus. Increased bleeding will occur if soft or “boggy.” Failing to support the lower uterine segment may result in inversion of the uterus.
You may also like to solve these questions
Where can the nurse expect to palpate the fundus at this time?
- A. Just above the symphysis pubis
- B. Just below the xiphoid process
- C. Near the level of the umbilicus
- D. Just below the symphysis pubis
Correct Answer: C
Rationale: At 20 weeks' gestation, the fundus is typically palpated near the level of the umbilicus, reflecting uterine growth.
The laboring client is experiencing problems, and the nurse is concerned about possible side effects from the epidural anesthetic just administered. Which problems should the nurse attribute to the epidural anesthetic? Select all that apply.
- A. Has breakthrough sharp pain
- B. Blood pressure is increased
- C. Has a pounding headache
- D. Unable to feel a full bladder
- E. Has an elevated temperature
Correct Answer: A,C,D,E
Rationale: Breakthrough pain can occur when the continuous infusion rate of the anesthetic agent is below the recommended rate for a therapeutic dose. Breakthrough pain can also occur when the client has a full bladder or when the cervix is completely dilated. A spinal headache can be a complication of epidural anesthesia and occurs when the dura is accidently punctured during epidural placement. A sensory level of T10 is usually maintained during epidural anesthesia; most women are unable to feel a full bladder or to void after receiving an epidural anesthetic. Maternal temperature may be elevated to 100.1°F (37.8°C) or higher with an epidural. Sympathetic blockade may decrease sweat production and diminish heat loss. Hypertension is a contraindication for epidural anesthesia. A major side effect of epidural anesthesia is hypotension (not hypertension) caused by a spinal blockade, which lowers peripheral resistance, decreases venous return to the heart, and subsequently lessens cardiac output and lowers BP.
Which screening is recommended for a client over 35 years old?
- A. Amniocentesis for genetic disorders
- B. Blood type screening
- C. Urine culture
- D. Basic ultrasound
Correct Answer: A
Rationale: Amniocentesis is recommended for women over 35 to screen for genetic disorders due to increased risk with advanced maternal age.
The nurse is evaluating the 39-weeks-pregnant client who reports greenish, foul-smelling vaginal discharge. Her temperature is 101.6°F (38.7°C), and the FHR is 120 with minimal variability and no accelerations. The client’s group beta streptococcus (GBS) culture is positive. Which interventions should the nurse plan to implement? Select all that apply.
- A. Prepare for cesarean birth due to chorioamnionitis
- B. Start oxytocin for labor induction
- C. Start antibiotics as directed for the GBS infection
- D. Prepare the client for epidural anesthesia
- E. Notify the neonatologist of the client’s status
- F. Administer a cervical ripening agent
Correct Answer: A,C,D,E
Rationale: Because this client is not in labor and chorioamnionitis is possible, a cesarean birth is indicated. The client should be given antibiotics as prescribed to treat the infection. Because epidural anesthesia offers the least risk to the fetus, preparation for epidural anesthesia should begin. The pediatrician or neonatologist should be notified and available for the impending delivery. Starting oxytocin (Pitocin) would prolong the time to delivery. Administering a cervical ripening agent would prolong the time to delivery.
The nurse is teaching the client who is wishing to travel by airplane during the first 36 weeks of her pregnancy. Which is the primary risk of air travel for this client that the nurse should address?
- A. Risk of preterm labor
- B. Deep vein thrombosis
- C. Spontaneous abortion
- D. Nausea and vomiting
Correct Answer: B
Rationale: The primary risk with air travel during pregnancy is DVT. Pregnancy increases the risk of blood coagulation, and prolonged sitting produces venous stasis. Preterm labor is not associated with air travel. The threat of spontaneous abortion diminishes during the second trimester. Spontaneous abortion is not associated with air travel. Although nausea and vomiting can occur, they are not dangerous.